SHA24/032004

Advances in Cardiac Surgery Minimally Invasive Cardiac Surgery Vinay Badhwar, MD Associate Professor of Surgery Department of Cardiothoracic Surgery Chief of Adult Cardiac Surgery, UPMC Presbyterian University of Pittsburgh

UPMC

Disclosures Nothing to disclose

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Innovation will not be accepted at first.

It takes repeated attempts, endless demonstrations, monotonous rehearsals before innovation can be accepted and internalized by an organization.

This requires 'courageous patience'.

Warren Bennis

A Story of Growth Through ‘Courageous Patience’ Minimally Invasive Cardiac Surgery “MIC” Early Childhood, Adolescence, Early Adulthood

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Objectives •

1990-1999 •

•

2000-2010 •

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Early clinical experience: AVR, MVrepair Technologic and Clinical Optimization: AVR, Mvrepair, CABG, Surgical Ablation

2010-present and future •

Multimodal Enhancements to Technology, Clinical Indications, System Integration 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

A Lineage of Innovation Lancet 1;352, 1902

Boston M & S Jour, 188:1023-1027, 1923

Sir Lauder Brunton, M.D.

Br. Med Jour 2:603 -606, 1925

Charles P. Bailey, M.D.

1948

Dwight E. Harken, M.D.

A Lineage of Innovation

Dwight McGoon, M.D. - 1958

Minimally Invasive Cardiac Surgery • Growth driven by minimal access surgery merits • ↓ surgical trauma and pain, ↑ speed of recovery

• Initial enthusiasm in cardiac surgery tempered • Reduced exposure for highly complex operations • Supportive technology not matured

• Modern era: Improvements in perfusion, imaging, instrumentation, clinical heart-team cooperation, safety, efficacy and value 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

MIC’s Early Childhood of the 1990’s • 1990 – beginnings as only a thought • 1995 – born with concepts and experimentation • 1996-1998 – Teething to running in 2 years • • • • •

1st Mini AVR – Parasternal Incision Mini AVR – upper hemisternotomy Mini MV repair – lower sternotomy Right Mini Thoracotomy – video assist (Leipzig) 1st successful robotic mitral repair (Carpentier)

• 1998-1999 – Bravely exploring • MIDCAB to 1st arrested-heart robotic assisted CABG

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

MIC’s Early Childhood of the 1990’s • Frenetic growth tempered by early limitations • • • • • • •

Reproducibility – few centers, few surgeons Safety – prolonged OR times Complications – myocardial protection, dissection, stroke Outcome benefit – length of stay, recovery time Precision of index operation Complexity of access Evolving techniques limiting widespread adoption

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

MIC’s Early Adolescence • 2000 – AVR mini upper sternotomy spreads • Direct central cannulation, good safety profile

• 2000-2005 – mini thoracotomy mitral surgery stable • • • •

Direct central cannulation option introduced Peripheral cannulation techniques modified Enhancement to myocardial protection Robotic experience limited to few centers

• 2000-2005 – mini CABG experience falters • Traditional “MIDCAB” outcomes and merits questioned • Alternatives developed while robotic use remains limited essentially to IMA harvesting 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

MIC’s Late Adolescence • 2005-2010 – mini AVR becomes well established • Mini upper sternotomy safe and effective, good outcomes, improvements in transfusion rates, length of stay • Mini upper lateral thoracotomy developed with similar outcomes but experience limited • TAVI access operations introduced (Trans-apical)

• 2005-2010 – mini MV repair expands adoption • Technologic improvements to instrumentation • Perfusion refinement, Central Cross Clamp and protection • Next generation robotic telemanipulation and mitral retractor introduced, enhancing surgical efficacy 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

MIC’s Late Adolescence • 2005-2010 – mini MAZE – surgical ablation evolves • Initial isolated epicardial pseudo-ablation “mini MAZE” failure • Mini mitral platform used to develop full bi-atrial Cox-MAZE

• 2005-2010 – mini CABG regroups and improves • MIDCAB replaced with “MICS CABG” to involve full IMA harvest, better instrumentation designed for mini approach • Hybrid ORs for imaging and/or combined procedures • Next generation robotic telemanipulation allows for development of totally endoscopic grafting (TECAB)

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Minimally Invasive Valve Surgery

MIC’s Adulthood Maturity • 2010-present – minimally invasive AVR reproducible • • • • •

Multi-year and multi-institutional risk-adjusted data Safe, reliable platform. Non-inferior operative outcomes Cost benefit established, reduced transfusion, LOS Most common minimally invasive cardiac operation Platform for Direct Access for TAVI, Sutureless Valves

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Minimally Invasive Surgical AVR

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

MIC’s Adulthood Maturity • 2010-present – minimally invasive Cox-MAZE IV • Concentrating of full MAZE lesion set • Rigorous follow-up with excellent short and mid-term results

• 2010-present – mini CABG established • • • •

MICS CABG expansion as reproducible option for LIMA-LAD Heart Team integration key step for cooperation Expansion of use of hybrid cath-integrated OR suites Next generation robotic telemanipulation allows for development of totally endoscopic grafting (TECAB) • Slow development, more time needed for maturity 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Bonatti J et al. Circulation 2011;124:236-244

Minimally Invasive CABG

MIC’s Adulthood Maturity • 2010-present – minimally invasive Mitral Repair standardized in high volume centers • • • • • • •

Preoperative imaging vastly improves perfusion strategy Most commonly direct cross-clamp, peripheral perfusion Outcomes established as non-inferior to open surgery Heart Team enhancement of cooperation (imaging, invasive) Pt/consumer demand – increase Asymptomatic severe MR 2nd wave of robotic mitral therapy Judicious re-induction of endo-balloon therapy

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Current Mini Mitral Standardization Preoperative imaging essential for vascular access and perfusion strategy • Case selection based on imaging • Technique consistency, TEAM consistency • Reproducibility in technique and performance allows for continued innovation •

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Never sacrifice outcome for incision 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

UPMC

UPMC

Mini MV Repair Approach

UPMC

Mini Mitral Exposure

UPMC

Videoscopic Minimally Invasive Mitral Repair

UPMC

Isolated Mitral Valve Solution

Robotic Mitral Valve Repair

UPMC

Isolated Mitral Valve Solution

Robotic Mitral Valve Repair

UPMC

Minimally Invasive Valve Surgery

Drivers of Outcome 2013 and Beyond •

Refinements in Anesthesia • • •

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Intra-thecal narcotics preoperatively Surgical inter-costal nerve blockade In-room extubation as a growing standard

Perioperative Care Standardization • • •

Out of bed to steps on POD 0 DC home POD 3-4 Similar to TAVR 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Minimally Invasive Valve Surgery

Drivers of Outcome 2013 and Beyond Current system must be cost conscious to afford technologic enhancement • Current financial success does not equal patient success • Success will be achieved by transforming to a value based system; value for patients Value = quality outcomes $ spent •

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

What’s Next •

Emerging Technologies • •

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Robotic second wave…cardiorobotics Integrated delivery of care – HEART TEAM

Quality Outcome Reporting – may be the most important driver of all…

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Value through data International Quality Collaborative (STS) 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013

Innovation is not a single action but a total process of interrelated sub processes.

It is not just the conception of a new idea, nor the invention of a new device, nor the development of a new market.

Innovation comes when all of these elements act in an integrated fashion as one to move our field forward.

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